{
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"FirstLineMailingAddress": "228 E ROUTE 59",
"SecondLineMailingAddress": null,
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"MailingAddressStateName": "NY",
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"MailingAddressCountryCode": "US",
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"FirstLinePracticeLocationAddress": "84 BA MAR DR",
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"PracticeLocationAddressCityName": "STONY POINT",
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"EnumerationDate": "11/11/2025",
"LastUpdateDate": "11/19/2025",
"NPIDeactivationReasonCode": null,
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "CREDENTIALING",
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"AuthorizedOfficialTitle": "OWNER",
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"AuthorizedOfficialTelephoneNumber": "845-499-5320",
"Taxonomies": {
"Taxonomy": {
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"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
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}
}
}
}